Health Board Area Research Articles

The prevalence of multiple sclerosis in Tayside, Scotland: do latitudinal gradients really exist?

To determine the prevalence of multiple sclerosis (MS) in the Tayside Health Board Area, Scotland, we carried out a population-based survey using four intersecting sources (Neurology Department records, a survey of general practitioners, Scottish Morbidity Records of discharges from hospitals and visual evoked response requests). A two-source capture-recapture model estimated survey coverage, and direct age-sex standardisation was used to take account of different population structures. Comparisons were made between the prevalence in Scotland and that in the rest of the United Kingdom. A total of 727 (definite and probable) and 880 cases (early, probable and possible) were identified using the criteria of Poser et al. and those of Allison and Millar in a population of 395,600 (1995 mid-year estimate). The prevalence of MS on 1 September 1996 was 184/100,000 (95% confidence interval 171-198) and 222/100,000 (95% confidence interval 210-240), respectively. The two-source capture-recapture model estimated that the survey was between 93% and 99% complete. Age-sex standardisation eliminated certain north-south differences in prevalence when comparisons were made with previous surveys. Diagnostic misclassification may also have influenced reported prevalence statistics. The prevalence is similar to that found in revised figures from the Grampian region in Scotland but significantly higher than recent estimates from England and Wales. Methodological differences may account for most of the reported differences between north and south, although there is still evidence to suggest that MS is more prevalent in northern Great Britain and Northern Ireland than in England and Wales.

Equity of renal replacement therapy utilization: a prospective population-based study.

This 1-year prospective survey assessed the incidence and characteristics of all patients starting renal replacement therapy (RRT) for end-stage renal disease in Scotland, and whether there is equity of utilization of RRT in terms of age, domicile and social circumstance. In the year studied, 104 patients per million population (533 patients) started RRT (390 per million population aged 65-75). In 23.5% the cause of ESRD could not be determined. Diabetes was the single most frequently identified cause (16%). The requirement for RRT rose with age, but over the country as a whole, patients aged over 75 years were under-represented. The majority of health boards provided RRT at a rate within 20% of the national rate. There was no difference in the median age at starting RRT between health boards. The spectrum of social deprivation of patients starting RRT was the same as that of the general population. There was no evidence that social deprivation influences acceptance on to the RRT program, although the relationship between ESRD and deprivation is complex. The utilization of RRT exceeded the minimum rate recommended by the Renal Association, although there was fluctuation between health board areas. The national requirement for resources to provide RRT is likely to rise further to care for an increasingly elderly population.

Attitudinal factors associated with community pharmacists' involvement in services for drug misusers.

To assess the relationship between pharmacists' attitudes towards drug misusers and the availability and provision of services for drug misusers. A cross-sectional postal questionnaire survey. All community pharmacies in Scotland (n = 1142). A total of 864 pharmacists managing community pharmacies on a day-to-day basis (response rate 79%). Descriptive data were collected on demography, drug misuse services provided and training in drug misuse. Attitude statements were used to measure attitudes to drug misusers, the role of the pharmacist in dispensing controlled drugs and providing injecting equipment, providing advice on drug misuse and financial aspects of service provision. Statements were incorporated into a scale which was correlated with behavioural data on whether and how services were provided. The attitude scale had good internal reliability and was unidimensional. Pharmacists that provided needle/syringe exchanges, sold needles/syringes, dispensed methadone, supervised the consumption of methadone and provided health promotion services to drug misusers had significantly more positive attitudes towards drug misusers. Attitudes were associated with health board area, sex and number of years registered as a pharmacist. After controlling for these characteristics, attitude was an independent predictor of whether needles/syringes were sold, methadone was dispensed and methadone consumption supervised. Addressing negative attitudes could encourage more pharmacists to provide services and enhance the process of service delivery.

Prescribing and dispensing for drug misusers in primary care: current practice in Scotland.

Substitute prescribing has increased in Scotland, as in the rest of the UK. Both GPs and pharmacists are becoming increasingly involved in service provision for drug misusers, but anecdotal evidence has suggested considerable variation in prescribing and dispensing practice. We aimed to gain baseline data on (i) current prescribing practice by medical practitioners and drug agencies, (ii) dispensing practice by community pharmacists across Scotland for the management of drug misuse and (iii) variations in practice between health boards. A structured questionnaire was posted to all community pharmacies in Scotland (n = 1142), in order to gather information on prescribing from prescriptions held at the time of the survey and information on current dispensing practice in managing drug misusers. The response rate was 79%. Sixty-one per cent of pharmacists were currently dispensing drugs for the management of drug misuse. The most frequently prescribed drug was methadone, dispensed by 46% of pharmacists, followed by diazepam (37%), dihydrocodeine (26%) and temazepam (25%). Sixty-five per cent of methadone prescriptions were dispensed daily on request from the prescriber. Of the 3387 people receiving a methadone prescription, 32.9% had to consume their daily dose on the pharmacy premises under a pharmacist's supervision. Nineteen per cent of pharmacies currently provided a service to supervise the consumption of methadone by clients and a further 14% were prepared to but had no current demand. The proportion of prescriptions requiring supervision of methadone consumption varied considerably between health board areas. Methadone is the most widely prescribed drug for drug misuse across Scotland, but there is considerable variation between health board areas in how prescribing is managed. Prescribing practice should be revised locally, in a process involving GPs and pharmacists. Pharmacists have an important role in preventing drug misuse in primary care, but need further support to optimize good practice.

The location of food stores in urban areas: a case study in Glasgow

During the late 1990s there has been an increasing interest in the concept of “food deserts” (populated areas with little or no food retail provision). It has been suggested that they are more likely to be found in deprived areas; however there has been little systematic research on their prevalence and distribution. This paper describes a preliminary analysis of the location of food outlets in the Greater Glasgow Health Board Area. Data were collected as part of a project on spatial variations in the price and availability of food. Based on all 79 multiple stores, and a 1 in 9 sample (n = 246) of all non‐multiple stores in the area, we did not find any evidence for the existence of food deserts, and found that food stores were more numerous in the more deprived localities and postcode districts in the study site.

Cost minimisation analysis of provision of oxygen at home: are the Drug Tariff guidelines cost effective?

Objectives: To determine the level of oxygen cylinder use at which it becomes more cost effective to provide oxygen by concentrator at home in Northern Ireland, and to examine potential...

Day surgery in Scotland: patient satisfaction and outcomes.

OBJECTIVE: To evaluate patients' views on the process and outcome of day surgery in Scotland, and to study patients' satisfaction with care in a range of specific procedures. DESIGN: Questionnaires...

The nature of child protection practices: an Irish case study

Child protection social work in Ireland has been expanding at a significant pace over the past decade, particularly since the implementation of the 1991 Child Care Act and the emergence of a number of child abuse ‘scandals’ since the early 1990s. One health board area in Ireland, itself subject to one of the most controversial child abuse inquiries, commissioned a research study into the nature of child protection practices in the area. The aim of the research was to evaluate the overall child protection system and to consider what impact, if any, new practice guidelines and procedures, implemented in the aftermath of the inquiry, had made on the service. This paper considers some of the key findings from the research and considers these in the context of the overall Irish child protection system. Three particular aspects of the research are focused on: the use of procedures and guidelines, the nature of interagency cooperation and the position of social workers within this, and the overall nature and direction of the child care system.

The role of Scottish area health boards in audit and clinical effectiveness.

The role of Scottish area health boards in audit and clinical effectiveness.

Acanthamoeba keratitis in Scotland: risk factors for contact lens wearers

Objective: To investigate risk factors for Acanthamoeba keratitis amongst contact lens wearers in Scotland. Design: Patients with Acanthamoeba keratitis in the Scottish study, all of whom wore contact lenses, were compared with 46 healthy asymptomatic contact lens-wearing controls. They were all visited at home for contact lens and environmental microbiological sampling. In addition, all 288 optical practices in the West of Scotland were polled for contact lens types and disinfecting solutions sold in 1995, and a sample, each of whom fitted more than 500 contact lenses per year, were polled for a second time. Independently, a poll was commissioned by the Eyecare Information Service in July/August 1995 to estimate the numbers of contact lens wearers in Scotland and the UK. Industry was polled for numbers of each contact lens disinfecting regimen sold in Scotland in 1995. Setting: West of Scotland, UK. Subjects: All contact lens wearers among the 3 million population of the West of Scotland Health Board Areas. Main outcome measures: Risk factors for Acanthamoeba infection and recommendations for its prevention. Results: When Acanthamoeba infection occurred, patients' home water systems were frequently (54%) found to be colonised by this amoeba. Patients more frequently washed their storage cases in tap water than controls (P< 0.05) with resulting contamination, kept storage cases wet rather than air drying them (P< 0.05), and had coliform bacteria cultured from the storage case (P< 0.05) and had viable Acanthamoeba within the storage case (P< 0.0001). Overall, patients were found to have significantly more risk factors than controls (P< 0.0001). The noncompliant use of chlorine tablet disinfection, or failure to disinfect contact lenses at all, was associated with increased risk (P< 0.05). Ionic high water content contact lenses (FDA group 4 material), when used without disinfection or with non-compliant use of low chlorine (Soflab®) tablet-based disinfection, were associated with increased risk of Acanthamoeba infection (P< 0.05). In log-linear modelling of risky hygiene behaviours associated with contamination of storage cases with Acanthamoeba, the most significant behaviour was found to be use of the less effective disinfection methods (chlorine tablets or no disinfection). However further investigation showed that these methods were associated with an increased probability of rinsing the storage case in tap water, so that these two behaviours are confounded in the group studied. Conclusions: Failure to disinfect contact lenses, non-compliant use of chlorine tablets and/or introduction of tap water rinsing of storage cases were associated with increased risk of Acanthamoeba infection. New multipurpose solutions and hydrogen peroxide gave the lowest risk of Acanthamoeba infection, with no statistically significant difference between them. Ionic high-water content (FDA group 4) contact lenses were at increased risk of being associated with Acanthamoeba keratitis if used without effective disinfection (multipurpose solutions or hydrogen peroxide). The use of domestic tap water for contact lens and storage case hygiene must be avoided, as a chain-of-causation' was identified from the home water supply.

Incidence and occupational pattern of leukaemias, lymphomas, and testicular tumours in western Ireland over an 11 year period.

STUDY OBJECTIVE: To determine incidence of the following malignancies, testicular tumours, all leukaemias and all lymphomas in the West of Ireland in an 11 year period. Secondly, to examine the...

Salmonella typhimurium DT104 infection in people and animals in Scotland: a collaborative epidemiological study 1993–96

This paper describes a comparative analysis of human and farm animal salmonellosis in Scotland between 1993 and 1996, with particular reference to Salmonella typhimurium definitive type 104 (DT104). Cattle were...

Variation in the survival of women with breast cancer in Scotland. The Scottish Breast Cancer Focus Group and The Scottish Cancer Therapy Network.

We have investigated factors influencing the survival of women with early breast cancer in Scotland. In a retrospective study, clinical, treatment and 'service' factors, e.g. surgical case load, deprivation and geographical area (health board of first treatment) were recorded from hospital records. A total of 2148 women with invasive breast cancer diagnosed in 1987 were identified from the Scottish Cancer Registry, of whom 1619 without metastases at diagnosis underwent surgery as part of their primary treatment. In a multivariate analysis, clinical factors (age, clinical stage, pathological tumour size, node status and oestrogen receptor status) all influenced survival. After allowing for these clinical factors, surgical case load and deprivation did not have statistically significant effects on survival. By contrast, health board did affect survival. This was explained in part by the selection of patients for surgery. There appeared, however, to be a residual effect that may be related to differences in the use of adjuvant systemic treatment among the different health boards. We conclude that, in Scotland, geographical variation in both surgical and non-surgical treatment has a greater effect on variability in survival for women with breast cancer than surgical case load and deprivation.

Referral rates and waiting lists: some empirical evidence.

This paper provides some empirical evidence on topics discussed at greater length in a recent paper in Health Economics (Goddard, J.A., Malek, M. and Tavakoli, M. Health Economics 1995; 4: 41-55), which modelled the relationship between referral rates and waiting lists for hospital treatment for non-urgent conditions within a queuing theory framework. Here, we estimate a version of the demand function used in this model, with panel data for Scottish Health Board Areas during the period 1990-1992. Separate models are estimated for each of six broadly defined 'waiting list' specialisms, for which we have data on referral rates and waiting times. The six specialisms are General Surgery, Ear Nose and Throat Surgery, Gynaecology, Ophthalmology, Orthopaedics and Urology.

Deficiencies in Leg Ulcer Care: A National Survey in Scotland

Objective: To identify what specialist expertise and services are currently available, in Scotland, to support general practitioners (GPs) and community nurses in the management of leg ulcer patients and the perceived need for the improvement of the service. Design: Postal questionnaires to randomly selected samples of GPs and community nurses. Setting: All 15 Scottish Health Board areas. Subjects: Six hundred and seventy-three GPs and 441 community nurses were questioned. Results: Five hundred and twelve (76%) GPs replied. Barely half, 285 (56%), expressed satisfaction with the service and only 155 (30%) had access to a recognized leg ulcer specialist. GPs who had access to a specialist expressed a greater level of satisfaction with the leg ulcer service than those without a local specialist. Community nurse questionnaire: Three hundred and sixty (82%) nurses replied. Two hundred and forty six (68%) indicated that the diagnosis of the cause of ulceration was usually made by both the GP and the nurse but the choice of treatment was most often made by the nurse alone. The great majority (69%) did not have access to a local leg ulcer clinic and only 34 (9%) indicated that they had access to management protocols, almost 90% of nurses expressing a need for protocols. Both questionnaires revealed a lack of specialist support, dedicated leg ulcer clinics, better education and training, and leg ulcer management protocols. Conclusion: Serious deficiencies in the support available for community care of leg ulcer patients have been identified. The situation requires to be remedied if more cost-effective outcomes for leg ulcer patients are to be achieved.

Attitudes of general practitioners to screening for cystic fibrosis.

To ascertain the views of general practitioners (GPs) about screening for cystic fibrosis. To find out whether and under what conditions they might play a part in the delivery of such programmes. All GP practices within the Lothian Health Board area. A self administered questionnaire was sent to each of the 532 GPs in the area. 334 (63%) GPs participated in the study. Only 23% of these claimed to have no professional or personal experience of the disorder. 77% of GPs were aware of the existence of a programme of antenatal screening for cystic fibrosis (CF), which had been running in Edinburgh for the past six years, with only 2% unfavourably disposed to it. However, when asked to rank CF screening against antenatal screening for spina bifida and Down's syndrome, or cervical and breast screening, 55% gave it the lowest priority. There was fairly equal support for the screening site being an antenatal clinic, a genetic centre, a family planning clinic, or a GP surgery, but little enthusiasm for programmes in schools or the workplace. Surprisingly, only 13% of GPs thought that screening should be offered to those with a negative family history of the disorder. Although the idea of involvement in screening was favoured, GPs claimed that any aspect of delivery that they undertook would need to be supported. There were no significant differences between the responses of fundholding GPs and non-fundholders. The low ranking by GPs of CF screening against other programmes, together with the need for support if they were to be involved, suggests that it is currently impractical to move the programme from its existing site in antenatal clinics.

Reduction in costs of inpatient stay associated with clozapine treatment: A retrospective study

SummaryClozapine is an atypical antipsychotic drug used to treat the 10-25% of patients who suffer from schizophrenia who are treatment resistant or intolerant to standard antipsychotic drug treatment. A major issue associated with treatment is the high cost of the drug compared to standard antipsychotic drug treatment. Research carried out to date has suggested that despite the high cost of clozapine, it is overall a cost-effective treatment. This contention is based on the findings described elsewhere that clozapine treatment is associated with a dramatic decrease in psychiatric inpatient stay.There are many ethical difficulties associated with a prospective double-blind controlled trial of clozapine treatment. We have therefore reported on a retrospective audit. A retrospective analysis was carried out by the examination of computerised patient records to determine if clozapine treatment had been associated with a reduction in psychiatric inpatient stay. Also examined was whether clozapine treatment had been associated with an overall shift from intensive therapeutic ward usage.For example, patients are moved from intensive care and acute wards to wards with less intensive therapeutic input such as continuing care and rehabilitation wards. The inpatient stay details for 76 patients prescribed clozapine since early 1991 were examined before and after clozapine treatment commenced. The main problem with this retrospective analysis is that without any control group observed over the same time period, it is very difficult to assess how much of the decrease in bed usage is related to either the natural history of the disease and/or to changes in bed use over time associated with changes in mental health service provision and the development of community facilities.Psychiatric inpatient stay decreased by a statistically non-significant average of 13.2 days (6%) in the first year of treatment (p=0.7692), a non-significant average of 34 days (15%) in the second year of treatment (p=0.0669), a significant average of 38.4 days (17%) in the third year of treatment (p=0.0007) and again by a significant average of 51.2 days (22%) in the fourth year of treatment (p=0.0011).The average cost per inpatient bed-day for the main psychiatric hospital in the Health Board's area is £90.86 (based on 100% occupancy rate, 1994/95 prices). The reduction in bed days identified was equivalent to a saving of £1,200 per patient in the first year of treatment, £3,090 per patient in the second year, £3,490 per patient in the third year and £4,652 per patient in the fourth year. The average annual cost of clozapine per patient is approximately £2,500.Clozapine treatment was also associated with a shift from intensive care and acute ward inpatient usage to continuing care and rehabilitative ward usage. In the year prior to clozapine treatment intensive care and acute ward stay accounted for 72.7% of total inpatient stay. In the first year of treatment this proportion decreased to 63.7%, in the second year to 39.5%, in the third year to 31.8% and in the fourth year to 24.6%. This represented potential savings of £500,000 per annum.Overall, the data generated from this study indicated that clozapine treatment is associated with both a reduction in psychiatric bed usage and a shift to less therapeutically intensive care wards. However, the decrease identified is not as dramatic as the reduction quoted elsewhere in the literature. These findings provide useful costing information to support the view that clozapine is a cost-saving or cost-neutral treatment in terms of the provision of psychiatric services in the UK. However, the costs associated with the increased use of community services by the study group were not identified in this review. In order to establish whether or not clozapine is cost saving overall compared to standard antipsychotic treatment it would have been necessary to identify all costs, including the whole range of community costs, before and after treatment commenced.

Population predictors of community health and social service use in Northern Ireland.

STUDY OBJECTIVE: To investigate the characteristics of elderly populations associated with variations in their use of community health and personal social services and to test the hypotheses that the variations...

Control of infection: a survey of general medical practices.

The aims of the study were (1) to assess current infection control practice within general medical practices and establish a base line; (2) to identify potential infection control problems; (3) to assess the need for local infection control guidelines or standards related to general medical practice; (4) to assess the need for educational provision. A survey was carried out, using questionnaire and structured interviews, of all general practices (92) within a Health Board area with a patient population of 561,300. Forty two (46 per cent) practices participated, serving 67 per cent of the patient population. Only three (7 per cent) practices had written infection control policies and only six (14 per cent) provided training on the subject. Thirty (71 per cent) practices had autoclaves; however, performance monitoring was poor. The majority of high-risk instruments were adequately decontaminated; of the medium-risk instruments, the auriscope speculum was the item most frequently inadequately treated [36 practices (88 per cent)]. Deficiencies were identified in treatment of blood spillage, and protective clothing provision was variable. The majority, 40 (95 per cent) practices, had systems to deal with clinical waste; however, only two (5 per cent) reported use of BS7320 sharps containers on domiciliary visits. Despite the recognized dangers, 23 (55 per cent) practices resheathed needles and only six (14 per cent) had first aid guidance for needlestick injuries. Only eight (19 per cent) practices knew and recorded staff immunity to hepatitis B following vaccination. Some deficiencies in infection control practice were identified and the need for policy guidance and staff training was highlighted.

The standardized prescribing ratio--a new method for comparing prescribing between GPs, controlling for patient age and sex.

To develop a method for comparing the proportion of patients on any drug or group of drugs for individual GP patient panels in Ireland, taking account of the age and sex structure of the panel. Calculations based on prescribing data for the fourth-quarter of 1995 supplied by the Irish General Medical Services Payments Board for the Eastern Health Board area.Setting-Five hundred and fifty Irish general practices serving 355,000 persons entitled to free medical care under the General Medical Services Scheme in the Eastern Health Board area (28% of the population). Weightings for number of persons prescribed each of four drug groups, and all drugs combined, for 22 age/sex groupings, leading to a single age/sex adjusted prescribing index-the standardized prescribing ratio (SPR) for each GPs practice population. The SPRs showed a large amount of variation from the average figure of 100 for practices of 1000 or more patients for all drugs and for each of the four drug groups studied: all drugs 54-125, antibiotics 52-165, H(2) antagonists/proton pump inhibitors 38-197, antidepressants 13-213 and thyroxine 33-175. Practices with above average SPRs for all drugs, antibiotics and H(2) antagonists/proton pump inhibitors were significantly larger than those with below-average SPRs. Practices with below average SPRs for thyroxine were significantly larger than those with above-average SPRs. The SPR provides a useful age/sex adjusted method of comparing prescribing between GPs and it can be applied to any drug or group of drugs.